<form method="post">
<table cellpadding="5" cellspacing="5">
<tr>
<th>[lang_user]</th>
<td><input type="text" name="donate_to" value="{val_acc}" /></td>
</tr>
<tr>
<th>[lang_price] ( {currency} )</th>
<td><input type="text" name="donate_amount" value="{val_amount}" /></td>
</tr>
</table>
<input type="submit" name="submit" value="Donate" />
</form>